HPV or Pap: Which test is best for cervical cancer?

Two doctors groups have said that HPV tests can reasonably replace Pap tests, or combinations of the two, which both screen for cervical cancer.

But not everyone is ready to jump onboard the new guidelines to use HPV tests as a primary-screening tool every three years for women 25 or older.

Some critics have countered that switching to HPV screens will lead to too many unnecessary colposcopies, which include a visual exam of the cervix and a small biopsy and can contribute to stress, discomfort and inconvenience.

Other doctors say the move toward HPV screening alone has been a long time coming and probably eventually will be commonplace, but they’re holding off on across-the-board changes in practice for a while.

The Society of Gynecologic Oncology and the American Society for Colposcopy and Cervical Pathology said that use of the HPV test alone is a good alternative to the Pap test or screening with both HPV and Pap tests, which has been more widely adopted in recent years.

They still recommend Pap tests for women 21 to 25 because HPV incidence is so high in that age group.

Their interim clinical guidance can be used until other medical societies update their recommendations, they said in a release this month.

The American Congress of Obstetricians and Gynecologists has not changed its guideline, nor has the U.S. Preventive Services Task Force. Both support HPV testing in conjunction with Pap tests for women 30 or older.

HPV is common, especially in younger women. The virus, which infects more than half of sexually active people at some point in their lives, usually passes without incident, but it can lead to cervical cancer.

The U.S. Food and Drug Administration has approved HPV testing as a primary test for cervical-cancer screening. It requires a swab of the cervix — like a Pap — and detects 14 types of HPV, including the two responsible for seven of 10 cervical cancers.

HPV testing misses less pre-cancer and cancer than Pap tests, according to the new guidance, which relies heavily on a study that was published in conjunction with the recommendation in the medical journal Gynecologic Oncology.

That study, which goes by the acronym ATHENA, looked at Pap and HPV testing in almost 42,000 women and found that HPV testing was as effective as Pap tests in younger women or combined tests in women 30 or over.

Another study, in which a panel of experts evaluated research including the ATHENA study, found that HPV testing was better than the Pap in detecting serious problems.

The panel recommended that women who test positive for the two most-dangerous types of HPV undergo immediate colposcopy, but that women who have one of the other strains can wait a year and have a repeat HPV test along with a Pap.

“It’s an interesting time for women to try and negotiate and for clinicians to navigate the landscape of screening for cervical cancer,” said Dr. David Cohn, chief of gynecologic oncology at Ohio State University’s Wexner Medical Center.

HPV leads to cervical cancer, but not everyone who has HPV will have cancer, he said.

The study showed that HPV tests led to the discovery of a lot more severe pre-cancerous lesions and that’s compelling, Cohn said. And some European countries already have moved to HPV screening as a primary method.

He and other doctors in Columbus say they want to see more evidence on HPV screening, but Cohn said he would consider HPV screening at three-year intervals “a reasonable strategy.” Testing at three-year intervals has become more common in recent years after recommendations from multiple medical groups.

Others aren’t quite there.

“There are several questions outstanding about this, and I think those questions need to be answered before the larger organizations go along with this recommendation,” said Dr. John Parker, of OhioHealth Obstetrics and Gynecology Physicians.

For now, Parker said, he’ll continue to recommend Pap tests for patients up to age 30, and HPV and Pap for those older than 30.

Switching to HPV testing could double the number of colposcopies, especially if that testing starts at age 25, he said. Frequent callbacks after screening can backfire if women begin to think positive screens almost never equal a problem, Parker said.

“Colposcopy certainly is not a test that a woman wants to have done,” Parker said. “It can be parallel to callbacks for further testing for mammograms. The higher the callback rate, the less likely (women are) to come back for another screening.

“The risk would be complacency in the population to stop the screening if you do too much testing.”

Dr. Laura Houser, who practices at Columbus Ob-Gyn’s Taylor Station East office, said most physicians within her group are doing combination testing.

She said the science does show that HPV testing is better, but she understands concerns about performing too many colposcopies.

“Even as long as 10 years ago, it has been postulated that this might be coming because of how strongly associated cancer is with HPV,” Houser said. “It’s based on sound science.”

Getting patients in for any screening remains a much bigger concern for doctors than whether they are screened with an HPV test, a Pap or both, Cohn said.

Half of women with cervical cancer never had a screening and another 10 percent had not had a screening within the five years before diagnosis, Parker said.

Di Crawford, a 48-year-old cervical-cancer survivor from Westerville, said her primary concern is that women don’t skip regular exams because they are confused about the evolving recommendations.

“I never missed an exam, and I always had the HPV screening done” since it became available, in addition to the Pap test, Crawford said. Both her Pap and her HPV screen came back positive when she was 43.

“I think that’s great if you can have HPV screening done and get a yay or a nay,” she said.

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